lecture 5 ppt
TRANSCRIPT
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[email protected][email protected] && [email protected]@mans.edu.eg
Cancer StomachCancer Stomach
Dr; Omar FaroukDr; Omar FaroukLecturer of Surgical Oncology & BreastLecturer of Surgical Oncology & Breast
Oncology CenterOncology Center -- MansouraMansoura UniversityUniversityIntercollegiate MRCS (England)Intercollegiate MRCS (England)
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GastricGastric NeoplasiaNeoplasia
BenignBenign
Gastric polypsGastric polyps common but usually not neoplastic(hyperplastic polyps. Hamartomas, ectopic pancreas)
AdenomasAdenomas (occur but are rare)
MalignantMalignant
GastricGastric AdenocarcinomaAdenocarcinoma Gastric LymphomaGastric Lymphoma
Gastric SarcomaGastric Sarcoma
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PathologyPathology
Epidemiology
Risk Factors
Gross Picture
Microscopy Spread
Staging
Prggnosis
ManagementManagement
Diagnosis
Clinical Presentation
Investigations
Treatment
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The second most common fatalmalignancy in the
world (after lung cancer) Commonest in Far East (Japan)
High mortality unless disease detected early
Male : Female = 2:[email protected]
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PathologyPathology
Gastric Adenocarcinoma (~ 95%)
Squamous Cell Carcinoma
Adenoacanthoma Carcinoid
Gastrointestinal stromal tumors (GISTs)
Lymphoma
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Vast majority are
adenocarcinomas
Arise on background ofchronic gastritis,
intestinal metaplasia,
dysplasia
Most cases advanced at
presentation
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Gross types
Polypoid
Ulcerative
Infiltrative (extreme is
linitis plastica
leather bottle
stomach)
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Japanese classification systemJapanese classification systemfor early gastric cancer (EGC)for early gastric cancer (EGC)
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T1 mucosa & submucosa
Japanese Endoscopic
Classification
Early GastricEarly Gastric
CarcinomaCarcinoma
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BorrmannBorrmann System ofSystem ofAdvanced gastric cancerAdvanced gastric cancer
Polypoid
Ulcerative
Cauliflower
Infiltrative
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Borrmanns type I adenocarcinoma
protruding polypoid mass in the antrum
Advanced Gastric CancerAdvanced Gastric Cancer
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Borrmanns type II adenocarcinoma
Ulcerative type
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Borrmanns type IV adenocarcinoma
marked infiltrative thickening of the wall, havingthe contour of a leather bottle (linitus plastica)
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Intestinal type(forms glands likecancers of colon
and oesophagus)
Diffuse typedissociated tumour
cells oftencontaining amucinous blob signet ring cells
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Lauren ClassificationLauren Classification
IntestinalIntestinal Environmental
Gastric atrophy,
intestinal metaplasia
Men > women
Increasing inc. w/ age
Gland formation
Hematogenous Spread
Microsatellite instability
APC gene mutations p53, p16 inactivation
APC, adenomatous
polyposis coli
DiffuseDiffuse Blood type A
Women > men
Younger age group
Poorly differentiated,
signet ring cells
Transmural / lymphatic spread
Decreased E-cadhedrin
p53, p16 inactivation
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PRIMARY TUMOR (T)TX Primary tumor cannot be assessed
T0 No evidence of primary tumorTis Carcinoma in situ: intraepithelial tumor without invasion of the lamina propria
TT11 Tumor invades lamina propria or submucosaT2 Tumor invades muscularis propria or subserosa
T2a Tumor invades muscularis propria
T2b Tumor invades subserosa
T3 Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent
structuresT4 Tumor invades adjacent structures
REGIONAL LYMPH NODES (N)
NX Regional lymph node(s) cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1 to 6 regional lymph nodes
N2 Metastasis in 7 to 15 regional lymph nodesN3 Metastasis in more than 15 regional lymph nodes
DISTANT METASTASIS (M)
M0 No distant metastasis
M1 Distant metastasis
American Joint Committee (AJCC) onCancer Staging ofGastric Cancer, 2002
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Stage Grouping
O Tis N0 M0
IA T1 N0 M0
IB T1 N1 M0T2a/b N0 M0
II T1 N2 M0T2 N1 M0T3 N0 M0
IIIA T2a/b N2 M0T3 N1 M0
T4 N0 M0
IIIB T3 N2 M0
IV T4 N13 M0T13 N3 M0
Any T Any N [email protected]
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Local infiltration (through wall of stomach to
peritoneum, pancreas etc)
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Lymphatic local and
regional lymph nodes
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Blood liver, lungs
Transcoelomic (across
peritoneal cavity). Ofteninvolves ovaries (esp.
signet ring cancer)
Krukenberg tumour.
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Classification ofClassification of
EsophagogastricEsophagogastric
Junction CancersJunction Cancers
Siewert and Stein1998 have developed a classification system for adenocarcinoma of the
esophagogastric junction. Now commonly referred to as the SiewertSiewert classificationclassification,
this system recognizes three distinct clinical entities that arise within 5 cm of the
junction of the tubular esophagus and the stomach:
Type 1adenocarcinoma of the distal esophagus, which usually arises from an area
with specialized intestinal metaplasia of the esophagus (i.e., Barrett's esophagus) and
may infiltrate the esophagogastric junction from aboveType IIadenocarcinoma of the cardia, which arises from the epithelium of the cardia
or from short segments with intestinal metaplasia at the esophagogastric junction
Type IIIadenocarcinoma of the subcardial stomach, which may infiltrate the
esophagogastric junction or distal esophagus from below
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Clinical PresentationClinical Presentation
AsymptomaticAsymptomatic Early (Dyspepsia):Early (Dyspepsia):
Vague epigastric discomfort / indigestion
Pain is constant, non-radiating, unrelieved by food digestion
More advanced diseaseMore advanced disease
Weight lossAnorexia
Fatigue
Emesis
EpigastricEpigastric MassMass Ulcer CancerUlcer Cancer GI bleedingGI bleeding ObstructionObstruction Occult presentationOccult presentation
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Clinical PresentationClinical Presentation
Physical signsPhysical signs latelate
Assoc. w/ locally advanced orAssoc. w/ locally advanced or metsmets
Palpable abdominal massPalpable abdominal mass
PalpablePalpable supraclavicularsupraclavicular (Virchows) LN(Virchows) LN PalpablePalpable periumbilicalperiumbilical (Sister Mary Josephs)(Sister Mary Josephs)
LNLN
PeritonealPeritoneal metsmets palpable by rectal exampalpable by rectal exam
((BlumersBlumers shelf)shelf) Palpable ovarian mass (Palpable ovarian mass (KrukenbergsKrukenbergs tumor)tumor)
S/S/SxSx ofof hepatomegalyhepatomegaly
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InvestigationsInvestigations
Endoscopy:Endoscopy:VisualizationVisualization
BiopsyBiopsyPalliationPalliation
Laser ablationLaser ablation
DilatationDilatation
TumorTumor stentingstenting
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Endoscopicclassic grossappearance ofbenign ulcer
1) relatively small
2) the radiatingrugal folds extendnearly all the wayto the margins ofthe base.
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Malignant
Ulcer
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InvestigationsInvestigations
EUSEUS-- Aid in stagingAid in staging
gastric wall tumor invasiongastric wall tumor invasion LN statusLN status
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Benign Gastric ulcer niche
Contrast imaging (Barium meal)
Malignant Gastric ulcer
InvestigationsInvestigations
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bariumexamination shows
irregular mucosalnodularity (white
arrows) multiple small
ulcerations (blackarrows) of the
antrum.
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CT scan of abdomenCT scan of abdomen Pelvic CT for women CT chest for proximal gastric
cancer
Limitations
< 5 mm mets liver/peritoneum
Staging for LN mets 25 86 %
InvestigationsInvestigations
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Diagnostic LaparoscopyDiagnostic Laparoscopy
evaluate peritoneal mets
Cytology of peritoneal fluid / peritonealCytology of peritoneal fluid / peritoneallavagelavage
+ finding poor prognosis
CBC, Routine preoperative lab.CBC, Routine preoperative lab.
Other InvestigationsOther Investigations
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Japanese Treatment ofJapanese Treatment ofEarly Gastric Cancer (TEarly Gastric Cancer (T11):):
Endoscopic ResectionEndoscopic Resection
((MucosectomyMucosectomy)) Photodynamic TherapyPhotodynamic Therapy
TreatmentTreatment
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Japanese Treatment ofJapanese Treatment ofEarly Gastric Cancer (T1):Early Gastric Cancer (T1):
Endoscopic ResectionEndoscopic Resection
((MucosectomyMucosectomy)) Photodynamic TherapyPhotodynamic Therapy
TreatmentTreatment
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Operable Operable RadicalRadical
GastrectomyGastrectomy
(R(R11 or Ror R22))++ ReanastmosisReanastmosis //
ReconstructiveReconstructive
pouchpouch
TreatmentTreatment
Extent of resection in gastric lymphadenectomy,
based on location of the primary cancer
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Distal SubtotalDistal SubtotalRadicalRadical GastrectomyGastrectomy
Subtotal / TotalSubtotal / TotalRadicalRadical GastrectomyGastrectomy
Proximal SubtotalProximal SubtotalRadicalRadical GastrectomyGastrectomy
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TreatmentTreatment
Inoperable PalliativeInoperable Palliative tttttt Palliative resectionPalliative resection
BypassBypass
FeedingFeeding JeujonostomyJeujonostomy
Radioresistant
Less chemotherapy response
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FutureFuture
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THANKTHANK
YOUYOU
Omar FaroukOmar FaroukLecturer of Surgical Oncology
Oncology Center. Faculty of Medicine. Mansoura University
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